Telus TPM Documentation

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__**Claims Pended**__

The Claims Pended screen can be accessed by clicking Pended in the Claim -> Claim View menu.

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The Claims Pended grid displays all claims in a Pended status and a option to view claims by Reason Code.
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**Claims Pended**

The left side of the screen displays the Claim Grid.  On this grid, there are two visibility filter options: Claim Visibility Grouping and Visible Indicator.  

__Claim Visibility Grouping__

This column displays the Grouping Description hierarchy for the group which has visibility to the claim based on Claimant. This column can be filtered to a group by entering the text in the column filter and clicking enter.

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__Visibility Indicator__

This column displays True or False.  It will display True if the current logged in user is in that Claim Visibility Grouping hierarchy and False if the user is not in that grouping.  Claim visibility will limit the claims displayed on the pending screen to Visible Indicator = true for users who have limited visibility.  

There is an Access Role (managed by an admin user) labeled "Claim – Visibility All" which allows users to view all pendings, not limited by visibility.  Users with this access role will have the option to filter the pending grid visibility indicator column.  Users without this role will only see claims where the Visible Indicator is true with no option to filter the column.


In the screenshot below, the user is in both the hierarchy2 and level A groups, but not the level 2 group.  To view all pended claims the user is responsible for, simply filter the Visible Indicator column to True.

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**Oldest Reason Date**

This displays the date of the oldest Pend reason for the Claim.  Use this column to sort by the oldest Pended Claims.

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**Contract ID**

Clicking the Contract ID will open a new tab for the contract selected.  Clicking the Contract ID Hyperlink for a contract not resolved to a specific version will direct the user to the Contract Search screen.  The Contract ID will be populated in the search criteria and generate results automatically.

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**Contract Creator**

The Contract Creator First Name and Last Name display on the Pending grid.  These columns will be blank if the Contract has not resolved to a specific version, or if there is no Contract assigned to the claim.

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**Claim Notes**

There is a column in the Claim Pended grid titled "Claim Notes".  This displays the notes associated with the pending claim.

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To view the note, or to add a new note, highlight a pending claim row and click the Claim Notes button at the bottom of the screen.  This will open the Notes dialog and display the claim-related note.  View or Add a note and click Cancel to close the dialog.

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**Column Filters**

All columns have a filter option.  Enter text into the field below the column label and click enter to filter the data.  To remove a filter, clear the text in the field and click Enter.  In the screenshot below, the grid is filtered to pended claims with "123" in the Invoice Number.

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**Filter Reason Codes**

The right side of the screen displays the percentage of claims per Reason Code and a corresponding % of 100.  This provides a quick overview of Pendings ranked in default order of greatest to least by reason code.  To see the claims pending for that reason, simply click to select a row and claims pending for that reason will populate the grid on the left.

In the below screenshot, 9.87% of claims are pending for Missing manufacturer sku.  Clicking on this row in the Filter Reason Codes grid automatically filters by this reason code.

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NOTE: Claims and line items can pend for multiple reasons.  When PEND (#) is displayed, click on the hyperlink to view all pendings for that claim.

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**Multi-Claim Assign Contract**

If there are multiple claims which need to be assigned to a single contract, that action can be done here for users with permissions.  

Select the claims to assign to the contract by either [ctrl + click] to select records one at a time or [shift + click] to select a group of records.  Then click the Link to Contract button.

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This will open up the Contract Search with default criteria of Claimable = True and Contract End Date greater than or equal to today's date of last year.  That criteria can be removed by clicking the X at the beginning of the criteria row.  Search for the contract and either double click the contract row or highlight the contract row and click the Select button.  This will display a message indicating the claims to which the contract was assigned.

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Once the contract is assigned to the claim, that claim will no longer be in a pended state as it needs to run through the calculate claim process to determine its updated state.  Go to the Claims Submitted grid to locate the claim if it hasn't run through the calculate claim process (calculate claim runs at :15 after the hour).  Open the claim to auto-run calculate claim and to work the claim in its updated state.
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**Mass Update Pending Lines and Mass reject claims at the header**

Multiple claims can be actioned at once to reject, recalc, override or unhold pending lines.  Select multiple claims by either [ctrl + click] to select records one at a time or [shift + click] to select a group of records. Once the claim rows are selected, click one of the Mass update options at the bottom of the screen.

Multiple claims can also be mass rejected at once. This would be used for a batch of claims where you want to reject the entire claim.

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Click on the pending reason to action and then click Commit.  Only the lines on the selected claims which had that pending reason will be actioned.  

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**Report - Claim Line Item Pending**

A detail report is available at the bottom of the Claims Pended screen.  This report displays the pended lines per claim by reason.

To run this report, click the report button.

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Click the Generate button.  Excel is the only Export Type available for this report.

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A wait message will display while the report is being generated.

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To open the report, click the hyperlink in the Generated Reports section.

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__Chart__

There is a Chart that displays a visual representation of Pendings by Reason Code.  

{{:pasted:20240820-172132.png}}

To view the claims pending for a specific reason, click on that portion of the chart and the data will display in the grid on the left.

The count related to each reason will display on hover over that reason.

Data can be removed/added to the chart by clicking the reasons listed below the chart.  Reasons will be greyed out that are not displaying in the chart.    

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**Enhanced Claim Line Item Status Classification**

A new pending reason designation has been implemented to improve claim processing accuracy. Claims associated with
terminated contract versions will now display a specific Terminated Contract status indicator, replacing the previous Out of Time Frame designation. This enhancement provides more precise identification of claim status rationale.

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**Automated Claims Rejection Enhancement**

Contract Hint Mapping - NPGS Integration

Feature Overview
An intelligent automated rejection system has been implemented to streamline claims processing for contracts designated as "Not Paid at GoSimple" (NPGS). This enhancement eliminates manual intervention requirements and significantly reduces processing overhead.

__Functional Specifications__

**Trigger Mechanism**
  * Contract Hint Mapping: When a contract hint is configured with NPGS - Not paid at GoSimple designation
  * Automatic Processing: Claims associated with NPGS-mapped contracts undergo immediate automated rejection upon creation
  * Real-Time Execution: Rejection occurs instantaneously during the claim creation workflow

**Process Automation**
  * Elimination of Manual Tasks: Removes requirement for manual claim rejection activities
  * Processing Efficiency: Significantly reduces time-to-resolution for NPGS-designated claims
  * Workflow Optimization: Streamlines overall claims processing pipeline

__System Behavior__

**Automated Actions**
  - Claim Creation Detection: System identifies newly created claims
  - Contract Hint Validation: Evaluates associated contract hint mappings
  - NPGS Status Check: Determines if contract is designated as "Not paid at GoSimple"
  - Automatic Rejection: Executes immediate claim rejection for NPGS-mapped contracts
  - Documentation: Appends standardized notation to claim record

**Audit & Documentation**
  * Automated Notation: System-generated notes clearly identify claims rejected through NPGS automation
  * Process Transparency: Distinguishes automated rejections from manual processing actions
  * Audit Trail: Maintains comprehensive record of all automated rejection activities

__Business Benefits__

**Operational Efficiency**
  * Time Reduction: Eliminates manual processing time for NPGS-designated claims
  * Resource Optimization: Frees staff capacity for higher-value claims processing activities
  * Consistency: Ensures uniform handling of NPGS claims across all processing scenarios

**Process Improvements**
  * Error Reduction: Minimizes human error in NPGS claim identification and rejection
  * Standardization: Implements consistent rejection methodology organization-wide
  * Scalability: Accommodates increased claim volumes without proportional resource increases

**Technical Implementation**
  * Integration Point: Seamless integration with existing contract hint mapping infrastructure
  * Performance Impact: Minimal system overhead with real-time processing capabilities
  * Configuration Management: Centralized NPGS designation management through contract hint interface

**Quality Assurance**
  * Validation Logic: Robust validation ensures accurate NPGS identification
  * Exception Handling: Comprehensive error management for edge cases
  * Monitoring: Automated tracking of rejection volumes and processing metrics

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